Re: Experiment
Kerry Douglas (kerry_at_cairns.net.au)
Mon, 4 May 1998 05:27:50 +1000
At 09:14 2/05/98 EDT, you wrote:
>
>Hi gang, I'm back.
> I spent last week in a TDY location presenting a Facilitator training
>class. It was quite interesting in that the facilities were less than ideal,
>but the lessons of overcoming barriers demonstrated that CRM can be discussed
>in a variety of locations and settings, to include the parking lot while the
>fire department checked out the building.
> I also experimented with the theme of the session, to provide repeated
>discussion of "error vs. violation", and some of our thoughts on error
>managenment, as we explored aviation events. Mixed in with this was a lot of
>"risk management", since that is the latest "buzz-word" in this culture. The
>discussions seemed to have been quite effective.
> Some of this class had been to several CRM classes before, and thought they
>knew the meaning and purpose of the training. As we finished off the week,
>many reported that they felt they had a much better understanding of what they
>had been exposed to in the past.
> The audience included some from the medical community, and one particular
>nurse enlightened us with the following story, which I think you'll find
>interesting:
>
> Once upon a time, in a hospital, a doctor told a nurse to administer some
>insulin to a diabetic patient. He told the nurse to give the patient "10 cc".
>The nurse thought that to be an unusually large amount, but did not question
>the order. She then went to the cabinet and noticed that the syringe she
>normally used for injections was too small, and hunted for a larger one. She
>then picked up a bottle of insulin from the cooler. These bottles only
>contain 5 cc, and usually last about a month. She, of course, had to use two
>complete bottles to collect the assigned amount. While she was injecting the
>patient, she even thought to herself, " . this is a lot for one dose." As
>you might imagine, shortly after the injection the patient went into shock.
> The investigation revealed that the doctor had indeed said "cc", and had
>even written "cc" on the records, thereby constituting a written order. The
>unfortunate truth is, however, the normal dosage is "units" which is not the
>same as "cc".
> To this day, the nurses of the organization often discuss this mishap,
>and wonder, how could this have happened? There were so many "flags" to catch
>the error, but the error slipped right through.
>
>Thought you might enjoy the analogy.
>
>And, oh by the way: interesting round on psycho-babble. I agree with the
>conclusions. The research and theories may be OK to guide the development of
>courses, but don't belong in the aviator's class room. I've often asked the
>CRM class students to start the morning with a group hug, and a song, but
>they refuse.
>
>Greg Deen
>Raytheon
>
>
>Hi Greg
Looking at your last paragraph. It seems that there is still confusion in
some areas of CRM around psychology theory/practice issues. I have never
heard of a CRM class starting with a group hug/song. Im not sure how it
illustrates your point.
Psychological theory and research whether to do with groups or whatever
originates in the real world of practice - its not the other way around.
Cheers Kerry